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ENROLMENT FORM
March 2018
*Mandatory Details
Anyone over the age of 16 years must complete their own enrolment form
Practice Name*
Doctor Name NZMC: EDI:
*NHI (Office use only)
Legal Name*
(Title) *Given Name *Other Given Name(s) *Family Name
Other Name (s)
Other Name Other Given Name(s) Other Family Name (eg. maiden name)
Preferred Name *Date of Birth *Place of Birth *Country of Birth
Preferred Name Day / Month / Year of Birth
Gender*
Gender diverse (please state)
Occupation
Male Female
Usual Residential
Address*
House (or RAPID) Number and Street Name Suburb Town / City and Postcode
Postal Address (if different from above)
House Number and Street Name or PO Box Number Suburb Town / City and Postcode
Contact Details
Mobile Phone Home Phone Email Address
Emergency Contact*
Name Relationship Mobile (or other) Phone
Community Services Card
Yes No Day / Month / Year of Expiry Card Number
High User Health Card Yes
No
Day / Month / Year of Expiry
Card Number
Smoking Status*
Smoker
If yes, would you like any support to quit? Yes No
Ex-Smoker Ex-Smoker Less than More than 15months ago 15months ago
Never Smoked
Ethnicity Details* Which ethnic group(s) do you belong to?
Tick the space or spaces which apply to you
New Zealand European
Iwi: ___________________________________________________________
Maori
Samoan
Cook Island Maori
Tongan
Niuean
Chinese
Indian
Other (such as Dutch, Japanese, Tokelauan). Please state;
Transfer of Records In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.
Yes, please request transfer of my records No transfer Not applicable
Previous Doctor and/or Practice Name Address / Location
Practice Logo
Page 2 of 2
My declaration of entitlement and eligibility*
I am entitled to enrol because I am residing permanently in New Zealand.
The definition of residing permanently in NZ is that you intend to be resident in New Zealand for at least 183 days in the next 12 months
I am eligible to enrol because:
a I am a New Zealand citizen (If yes, tick box and proceed to I confirm that, if requested, I can provide proof of my eligibility below)
If you are not a New Zealand citizen please tick which eligibility criteria applies to you (b–j) below:
b I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010)
c I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years
d I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included)
e I am an interim visa holder who was eligible immediately before my interim visa started
f I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking
g I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a–f above OR in the control of the Chief Executive of the Ministry of Social Development
h I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old)
i I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme
j I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund
I confirm that, if requested, I can provide proof of my eligibility* Evidence sighted (Office use only)
My agreement to the enrolment process* NB. Parent or Caregiver to sign if you are under 16 years
I intend to use this practice as my regular and on-going provider of general practice / GP / health care services.
I understand that by enrolling with this Practice I will be included in the enrolled population of Pegasus Health Charitable Ltd PHO (Primary Health Organisation) and my name address and other identification details will be included on the Practice, PHO and National Enrolment Service Registers.
I understand that if I visit another health care provider where I am not enrolled I may be charged a higher fee.
I have been given information about the benefits and implications of enrolment and the services this practice and PHO provides along with the PHO’s name and contact details.
I have read and I agree with the Use of Health Information Statement. The information I have provided on the Enrolment Form will be used to determine eligibility to receive publicly-funded services. Information may be compared with other government agencies but only when permitted under the Privacy Act.
I understand that the Practice participates in a national survey about people’s health care experience and how their overall care is managed. Taking part is voluntary and all responses will be anonymous. I can decline the survey or opt out of the survey by informing the Practice. The survey provides important information that is used to improve health services.
I agree to inform the practice of any changes in my contact details and entitlement and/or eligibility to be enrolled.
Signatory Details*
Signature Day / Month / Year Self Signing Authority
An authority has the legal right to sign for another person if for some reason they are unable to consent on their own behalf.
Authority Details (where signatory is not the enrolling person)
Full Name Relationship Contact Phone
Basis of authority (e.g. parent of a child under 16 years of age)
General Prac
ce provides com
prehensive primary,
comm
unity‐based and connuing
paent‐centred health care to
paents enrolled w
ith them
and others who consult.
General Prac
ce services include the diagnosis, m
anagement
and treatment of health condi
ons, con
nuity of health care throughout the lifespan,
health promo
on, preven
on, screening and referral to hospital
and specialists.
For further informa
on
Visit ww
w.legisla
on.govt.nz to access the Health Act 1956, O
fficial Inform
aon Act 1982 and Privacy Act 1993
The Health Informa
on Privacy Code 1994 is available at w
ww
.privacy.org.nz. You can also use the Privacy Com
missioner’s Ask U
s tool for privacy queries.
A copy of the Health and Disability Comm
iee’s
Standard Opera
ng procedures can be found at h
p://ethics.health.govt.nz/operang‐procedures
Further detail in regard to the ma
ers discussed in this Fact Sheet can be found on the M
inistry website at
hp://w
ww
.health.govt.nz/your‐health/services‐and‐support/health‐care‐services/sharing‐your‐health‐inform
aon
Complaints
It’s OK to com
plain if you’re not happy with the w
ay your health inform
aon is collected or used. Talk to
your healthcare provider in the first instance. If you are s
ll unhappy with the response you can call the
Offi
ce of the Privacy Comm
issioner toll‐free on 0800 803 909, as they can inves
gate this further.
Contact Details:
Pegasus Health (Charitable) Ltd 401 M
adras Street PO
Box 741 Christchurch 8140 Phone: 379 1739 w
ww
.pegasus.org.nz
Enrolling w
ith G
eneral Practice G
uide
Use of your health inform
aon
Below are som
e examples of how
your health inform
aon is used.
● If your pracce is contracted to a Prim
ary Health O
rganisaon (PHO
), the PHO m
ay use your informa
on for clinical and adm
inistrave purposes including
obtaining subsidised funding for you. ● Your District Health Board (DHB) uses your inform
aon to provide treatm
ent and care, and to im
prove the quality of its services. ● A clinical audit m
ay be conducted by a qualified health prac
oner to review the quality of services
provided to you. They may also view
health records if the audit involves checking on health m
aers.
● When you choose to register in a health program
me
(eg imm
unisaon or breast screening), relevant
informa
on may be shared w
ith other health agencies. ● The M
inistry of Health uses your demographic
Informa
on to assign a unique number to you on the
Na
onal Health Index (NHI). This N
HI number w
ill help iden
fy you when you use health services.
● The Ministry of Health holds health inform
aon to
measure how
well health services are delivered and to
plan and fund future health services. Auditors may
occasionally conduct financial audits of your health prac
oner. The auditors may review
your records and m
ay contact you to check that you received those services. ● N
ofica
on of births and deaths to the Births, Deaths and M
arriages register may be perform
ed electronically to stream
line a person’s interacons
with governm
ent. Research Your health inform
aon m
ay be used in research approved by an ethics com
mi
ee or when it has had
idenfying details rem
oved. ● Research w
hich may directly or indirectly iden
fy you can only be published if the researcher has previously obtained your consent and the study has received ethics approval. ● U
nder the law, you are not required to give
consent to the use of your health informa
on if it’s for unpublished research or sta
scal purposes, or if it’s
published in a way that doesn’t iden
fy you.
What is a PH
O?
Primary
Health O
rganisaons
are the
local structures
for delivering
and co‐ordina
ng prim
ary health
care services.
PHO’s
bring together
Doctors, N
urses and
other health
professionals (such as Maori health w
orkers, health
promoters,
diecians,
pharmacists,
physiotherapists, mental health w
orkers and m
idwives)
in the
comm
unity to
serve the
needs of their enrolled populaons.
PHO’s receive a set am
ount of funding from
the government to ensure the provision of a
range of health services, including visits to the Doctor.
Funding
is based
on the
people enrolled w
ith the PHO and their characteris
cs (e.g. age, gender and ethnicity.) Funding also pays for services that help people stay healthy and services that reach out to groups in the com
munity w
ho are missing out on health
services or who have poor health.
Benefits of Enrolling Enrolling is free and voluntary. If you choose not
to enrol
you can
sll
receive health
services from a chosen G
P / General Prac
ce / provider of First Level prim
ary health care services. Advantages of enrolling are that your visits to the Doctor w
ill be cheaper and you will
have direct access to a range of services linked to the PHO
. H
ow do I enrol?
To enrol, you need to complete an Enrolm
ent Form
at the General Prac
ce of your choice. Parents can enrol children under 16 years of age but children over 16 years need to sign their ow
n form.
Pegasus Health (Charitable) Ltd (Pegasus)
Your general pracce provider is affi
liated to Pegasus. Pegasus provides PHO
services and its fund‐holding role allow
s an extended range of services to be provided across the collec
ve of providers. Addi
onally, Pegasus provides clinical governance, quality and educa
on support to its mem
bers.
Q&
A W
hat happens if I go to another General Prac
ce? You can go to another G
eneral Pracce or change to a
new G
eneral Pracce at any
me. If you are enrolled
in a PHO through one G
eneral Pracce and visit
another Pracce as a casual pa
ent you will pay a
higher fee for that visit. So if you have more than one
General Prac
ce you should consider enrolling with
the Pracce you visit m
ost oen.
What happens if the G
eneral Pracce changes to a
new PH
O?
If the General Prac
ce changes to a new PHO
, the Prac
ce will m
ake this informa
on available to you.
What happens if I am
enrolled in a General Prac
ce but don’t see them
very oen?
If you have not received services from your G
eneral Prac
ce in a 3 year period it is likely that the Pracce
will contact you and ask if you w
ish to remain w
ith the Prac
ce. If you are not able to be contacted or do not respond, your nam
e will be taken off the Prac
ce and PHO
Enrolment Registers. You can re‐enrol w
ith the sam
e General Prac
ce or another General Prac
ce and the affi
liated PHO at a later
me.
Health Inform
ation Privacy Statement
Your privacy and confidenality w
ill be fully respected. This fact sheet sets out w
hy we collect your inform
aon and how
that inform
aon w
ill be used. Purpose W
e collect your health informa
on to provide a record of care. This helps you receive quality treatm
ent and care when you
need it. We also collect your health inform
aon to help:
● keep you & others safe ● plan and fund health services
● carry out authorised research ● prepare &
publish stas
cs ● train healthcare professionals ● im
prove government services.
Confidenality and inform
aon sharing
Your privacy and the confidenality of your inform
aon is
really important to us.
● Your health praconer w
ill record relevant informa
on from
your consultaon in your notes.
● Your health informa
on will be shared w
ith others involved in your healthcare and w
ith other agencies with your consent,
or if authorised by law.
● You don’t have to share your health informa
on, how
ever, withholding it m
ay affect the quality of care you receive. Talk to your health prac
oner if you have any concerns. ● You have the right to know
where your inform
aon is kept,
who has access rights, and, if the system
has audit log capability, w
ho has viewed or updated your inform
aon.
● Your informa
on will be kept securely to prevent
unauthorised access. Inform
aon quality
We’re required to keep your inform
aon accurate, up‐to‐date
and relevant for your treatment and care.
Right to access and correct ● You have the right to access and correct your health inform
aon. You have the right to see and request a copy of
your health informa
on. You don’t have to explain why you’re
requesng that inform
aon, but m
ay be required to provide proof of your iden
ty. If you request a second copy of that inform
aon w
ithin 12 months, you m
ay have to pay an adm
inistraon fee.
● You can ask for health informa
on about you to be corrected. Prac
ce staff should provide you with reasonable
assistance. If your healthcare provider chooses not to change that inform
aon, you can have this noted on your file. M
any prac
ces now offer a pa
ent portal, which allow
s you to view
some of your prac
ce health records online. Ask your pracce
if they’re offering a portal so you can register.
Enrolling with a Prim
ary H
ealth Organisation (PH
O)
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